New York Medicaid covers ABA for members under 21 with autism spectrum disorder or Rett syndrome — a young benefit (first billable in 2021, nine years after the state's commercial mandate) with a split personality. At the fee-for-service layer, administered through eMedNY, there is no prior authorization at all: the entire front door is a practitioner referral valid for up to two years. But since January 1, 2023 the benefit is carved into every mainstream Medicaid Managed Care plan, most children sit in one of those ~13 plans, and every major plan does impose its own prior authorization. In practice, "does this family need a PA?" is answered by which card they carry — which makes plan identification the first intake question in New York.
Nothing in the current FFS ABA Policy Manual (updated October 1, 2025) requires prior authorization or prior approval — for the assessment or for treatment. The gate is a referral from a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant (LBAs cannot diagnose or self-refer). The referral is valid for no more than 2 years and must carry a specific payload: the member's age, the ASD and/or Rett diagnosis with date of initial diagnosis, co-morbid diagnoses, severity level, a statement of need for ABA, and the DSM-5 Diagnostic Checklist. Once services start, the treatment plan must be updated at least every 6 months and shared with the referring provider. For intake, that means a complete referral packet is the whole authorization battle on FFS — chase its required elements at first contact, because an incomplete referral is the only thing standing between the family and a booked assessment.[1][30][31][20][6]
One proposal that did NOT make it into law: the Governor's FY 2026-27 Executive Budget floated an ABA "Centers of Excellence" (CoE) designation framework whose criteria were never defined. We read the actual enacted Health and Mental Hygiene budget bill text — S9007-C/A10007-C, signed as Chapter 57 of the Laws of 2026 — directly from the Legislature's bill-text archive, in full, and it contains zero occurrences of "Centers of Excellence," "Applied Behavior Analysis," or "ABA" anywhere in its text. The CoE framework did not survive into the enacted budget. The ABA rate reduction that did take effect (97153 to $9.63/unit, 10/1/2026) was carried out administratively instead, through Medicaid State Plan Amendment #25-0061 (effective 10/1/2025, superseding TN #22-0044) and the DOH Medicaid Update notices, not through this statute. The Department of Health's FY 2027 Enacted Budget Medicaid Scorecard's single ABA line — "Applied Behavioral Analysis Reforms," scored at ($13.7) million state share in FY 2027 — is consistent with that administrative rate action, not a CoE program.[1][30][31][20][6]
Reauthorization does not exist at the fee-for-service layer, so there is no reauth packet — but the 6-month treatment-plan update has a defined data payload. The manual requires the plan to carry, for each goal, “baseline data reported in objective terms (e.g., frequency, intensity, duration, etc.),” the “sampling method for ongoing data collection,” and “current data expressed by the same data collection method as the baseline data so that progress can be measured,” and says “LBAs will update the treatment plan at least every 6 months or as needed,” with “updated goals and data.” It does not require graphs; graphed data is a managed-care plan requirement where a plan imposes it (Fidelis, for one, asks for graphs).[1][30][31][20][6]
Effective January 1, 2023, ABA was carved into the mainstream Medicaid Managed Care benefit package — and since most children are enrolled in MMC, most New York ABA runs through a plan, not through eMedNY. The state's own manual is blunt about what that means: providers serving an MMC member "must contact the MMC member's specific MMC plan for coverage, billing, and reimbursement guidance." Unlike the FFS layer, every major plan imposes prior authorization, each with its own machinery — Fidelis's Centene-style clinical policy, UnitedHealthcare's Optum portal, Anthem's Availity form, Healthfirst, MetroPlus, EmblemHealth, and Molina all have dedicated guides below.[5][1][17]
The carve-in also runs through the regional upstate plans per the eMedNY directory (v2026-2, April 1, 2026): Excellus BCBS (Central NY, Rochester, Southern Tier), MVP Health Plan and CDPHP (Capital Region and Hudson Valley), and Independent Health and Highmark Western & Northeastern NY (Western NY), plus the HIV-SNPs (Amida Care, MetroPlus Partnership) and HARP variants — each now has its own dedicated guide below. Per the state's July 2026 Medicaid Managed Care enrollment report, the five regional plans carry real scale, not a rounding error: Excellus (179,533 statewide members), MVP (165,151), CDPHP (80,854), Independent Health (60,812, Erie County only), and Highmark Western & Northeastern NY (45,881) — roughly 532,000 members combined. One trap: Aetna Better Health appears in the NY directory only as a Partial LTC (MLTC) plan — it is not a mainstream children's Medicaid plan and not an ABA payer in NY Medicaid.[5][1][17]
The FFS fee schedule is flat: one statewide rate per code, no credential tiers, no modifiers, no geographic variation. Assessment (97151) and the QHP codes (97155 protocol modification, 97156 family guidance) pay $19.26 per 15-minute unit; group codes 97154/97157/97158 pay $3.31 per unit per member. The story is 97153, technician-delivered direct treatment — the volume code of every ABA practice. The FY 2025-26 enacted budget authorized a phased 25% cut applied only to 97153: $19.26 → $16.85 effective October 1, 2025 → $14.45 effective April 1, 2026. A NYSABA/CASP survey reported 74% of Medicaid ABA providers would leave the program if the second tranche took effect; the FY 2026-27 Executive Budget nonetheless layered on roughly $28.5M in further cuts. Two modeling notes: MMC plans negotiate their own rates (the state schedule is the FFS reference, not binding on plans), and any margin model built on pre-cut 97153 rates is now ~25% wrong.[2][1][4][3][6]
The third step is now in effect. The August 2026 Medicaid Update states that, “as authorized by the New York State (NYS) Enacted Budget for Fiscal Year 2026-2027, NYS Medicaid fee-for-service (FFS) will decrease the fee paid for” technician-delivered 97153, and that “effective October 1, 2026, the reimbursement for CPT code 97153 will be reduced to $9.63/per unit” — a further third off the $14.45 rate, and exactly half the pre-cut $19.26. No other ABA code changes: 97151, 97152, 97155 and 97156 stay at $19.26 and the group codes at $3.31 per member. The rate history for 97153 is $19.26 before October 1, 2025; $16.85 from October 1, 2025; $14.45 from April 1, 2026; and $9.63 from October 1, 2026 — the current rate as of this writing. The eMedNY fee-schedule spreadsheet has since been reissued: re-downloaded October 18, 2026, it is headed “Effective Date: October 1, 2026” and lists 97153 at $9.63, 97151/97152/97155/97156 at $19.26 and 97154/97157/97158 at $3.31 per unit per member. Code set: the ABA fee schedule and the manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014) — so New York Medicaid ABA is billed on the CPT codes alone. The notice is written for FFS; MMC plans set their own rates by contract, so ask each plan whether and when it follows the FFS change.[2][1][4][3][6]
New York is one of the strictest licensure states in the country: only NYSED Licensed Behavior Analysts (LBAs) can enroll in Medicaid and bill — a BCBA credential alone is not sufficient. Certified Behavior Analyst Assistants (CBAAs) enroll as non-billing (OPRA) providers and bill through their supervising LBA, and unlicensed technicians may deliver scripted 97153 sessions billed under the LBA's NPI. Effective October 1, 2025, that supervision has teeth: LBAs must supervise unlicensed technicians for at least 5% of the technician's service hours each calendar month, with at least 2 face-to-face real-time contacts per month (one observing service delivery), and no LBA may supervise more than 6 CBAAs/unlicensed individuals at a time — rules that apply to FFS and MMC alike, and that turn supervision capacity into a hard cap on census. Other operational rules worth wiring into intake: ABA is not reimbursable in a school setting (home, clinic, and community are fine); records must be kept at least 6 years and, for minors, until the patient turns 22 (10 years for MMC providers); and ABA-via-telehealth was under formal state evidence review in mid-2025 — supervision of technicians may already occur via synchronous audio/video.[4][1]
New York has no RBT mandate. The FFS manual defines the technician tier simply as an "unlicensed individual" — someone not licensed, certified, or registered by the state as an ABA provider — with no credential, training-hour, age, or education requirement attached. What the state regulates instead is scope: an LBA may not delegate any task within the ABA scope of practice, even under direct supervision, so technicians only execute the scripted treatment-plan activities the LBA wrote, record data without interpreting it, prepare the setting, and write factual session notes. The middle tier is unique to New York: the Certified Behavior Analyst Assistant (CBAA), a NYSED credential under Education Law Article 167 requiring a bachelor's degree (in ABA, or a related field plus ABA certificate coursework), 1,000 hours of supervised experience, and passage of both the NYCBAA and NY Autism exams. And if you staff with RBTs anyway — many agencies do — the BACB's own floor travels with the credential: 18+, high-school education, the 40-hour training and competency assessment, and a passed criminal background check plus abuse-registry check no more than 180 days before the certification application.[1][8][9][10][11][12][7][13][14]
On background screening, the ABA Policy Manual itself imposes no employee-level background-check, fingerprinting, or registry requirement — the obligations arrive from adjacent rules, keyed to what your agency is. At provider enrollment, NY Medicaid screens applications at the federal limited/moderate/high risk tiers and collects the $750 federal application fee (2026) from certain provider types (waived if you are enrolled in Medicare or another state's Medicaid or CHIP program, or the fee has already been paid to Medicare; a hardship waiver can be requested); enrollment fingerprinting attaches only at the high-risk tier, so confirm your risk category with provider enrollment. Justice Center pre-employment checks — Staff Exclusion List check first, then a fingerprint-based criminal background check via IdentoGO, fully completed before the hire has regular unsupervised contact with recipients — bind programs under Justice Center jurisdiction (OMH- and OPWDD-operated/certified programs, OCFS residential programs for children), not a standalone LBA practice billing Medicaid FFS; but an agency that also runs OPWDD-certified services (e.g., community habilitation) carries the full four-check stack: SEL, CBC, an MHL 16.34 check, and the OCFS child-abuse SCR check. Every agency, whatever its settings, should screen staff against the three exclusion databases OMIG names — the NYS Medicaid exclusion list, the federal OIG LEIE, and SAM.gov; OMIG doesn't publish a check frequency, so set a recurring cadence in your compliance plan.[1][8][9][10][11][12][7][13][14]
The supervisor credential is the LBA, and New York is explicit that BCBA certification alone "is not sufficient" to practice — it's only a pathway to licensure, which requires a master's from a NYSED-registered ABA program (or substantial equivalent), the exam (BCBA satisfies it), supervised experience, good moral character, minimum age 21, NYSED-approved child-abuse-reporting coursework, and a $300 fee. The supervision math covered above — 5% of each technician's monthly service hours, two face-to-face contacts, the six-supervisee cap — is what turns those credentials into a staffing model. Plans then layer on their own stacks: Optum/UHC Community Plan requires network LBAs to hold active BCBA certification plus the NY license plus a NY Medicaid ID (CBAAs need their own Medicaid ID), along with professional liability insurance and a virtual-visits attestation for telehealth supervision; Healthfirst stretches record retention to 10 years for MMC providers (vs. the state's 6-year/age-22 floor). No NY Medicaid plan we checked requires RBT certification for technicians.[1][8][9][10][11][12][7][13][14]
At the fee-for-service layer the conditions are licensure and enrollment, not a network decision. “LBAs must be licensed, and CBAAs must be certified, by the NYS Department of Education (NYSED) to enroll and participate in the NYS Medicaid FFS program,” and “an LBA must be enrolled with the NYS Medicaid FFS program to receive reimbursement for ABA services provided to a NYS Medicaid FFS or MMC member.” The ABA manual states no enrollment cap or moratorium; enrollment is revalidated every 5 years. Managed care is a separate door: providers serving an MMC member “must contact the MMC member’s specific MMC plan for coverage, billing, and reimbursement guidance,” so whether a plan’s ABA network is taking new groups is that plan’s contracting decision — with eMedNY enrollment the precondition for both.[1]
On fee-for-service there is no authorization to transfer, because the manual requires none. The gate is a referral “for ABA services” that is “valid for no more than two years”; the manual does not tie it to a named LBA and sets no one-provider-at-a-time rule. What it does require is continuity paperwork: every treatment plan must include a “plan for coordination with other providers” and “plans for transition and discharge of services,” and initial plans and updates “should be shared with the referring provider.” For a managed-care member the authorization sits with the plan, and the state manual leaves transfers to each plan — ask the plan whether the existing authorization can move to the new provider or a new request is needed.[1]
eMedNY’s General Billing manual: "Medicaid regulations require that claims for payment of medical care, services, or supplies to eligible beneficiaries be initially submitted within 90 days of the date of service to be valid and enforceable, unless the claim is delayed due to circumstances outside the control of the provider"; a late claim with an allowed delay reason must be submitted within 30 days of the delay ending, with a numeric delay reason code, and every claim must be finally submitted and payable within two years of the date of service. Managed care members are billed to their plan, not eMedNY.[21][32][33][22][23]
Electronic Visit Verification applies to Medicaid personal care and home health care services under the 21st Century Cures Act. The Department of Health’s list of EVV-applicable billing codes for fee-for-service and managed care contains no ABA code (97151–97158), so ABA sessions are not EVV-reported.[21][32][33][22][23]
Corrections, other insurance and the payment cycle. A claim returned for data insufficiency or claiming errors “must be corrected and resubmitted within 60 days of the date of notification,” and a paid claim needing correction goes in as an adjustment (not a void, in most cases) within 60 days of notification; a claim not correctly resubmitted within 60 days, or still unpayable after the second resubmission, is neither valid nor enforceable. Other coverage is billed first — “claims must be submitted to Medicare and/or other Third Party Insurance before being submitted to Medicaid” — and a claim delayed by that payer’s processing carries delay reason code 7 and must be submitted “within 30 days from the date submission came within the control of the provider” (paper claims with the Explanation of Medical Benefits). eMedNY pays on a weekly cycle: cycles run Thursday to Wednesday, the check (issue) date is the following Monday, and EFT and paper checks go out on the check release date, “the Wednesday, 2 weeks and 2 days following the check date.” The submission cut-off: “send them to the eMedNY system before 6:00 PM on Monday” for the best chance of the current week’s cycle; later claims are processed when possible and otherwise fall into the next weekly cycle. Insurance Law § 3224-a’s 30/45-day clock is written for insurers and managed-care plans; fee-for-service pays on this cycle.[21][32][33][22][23]
The questions that decide whether a family can start with New York Medicaid (NYS DOH / eMedNY), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. ABA “will be covered for NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) members under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and/or Rett Syndrome.” No minimum age is set, and there is no waiver pathway and no adult coverage — so the 21st birthday is a hard coverage cliff worth flagging at intake for any member 19 or older.[1]
New York regulates the referral’s age, not the evaluation’s. “Referrals for ABA services are valid for no more than two years” and must carry the “date of initial diagnosis” — but the manual sets no maximum age on the diagnostic report itself, so an older evaluation can still support a fresh referral. Once services start, “LBAs will update the treatment plan at least every 6 months or as needed,” and initial plans and updates “should be shared with the referring provider.” Managed-care plans layer tighter clocks on top (Fidelis runs a 2-year evaluation window plus a 60-month validated-tool rule; MetroPlus’s annual re-validation applies to its marketplace members, not Medicaid), so the card decides the operative recency rule.[1]
“The NYS Medicaid member must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” and those referring providers “should follow the criteria for diagnosing ASD found in the DSM-5 and outlined in the NYS Department of Health’s publication, Clinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders.” LBAs and CBAAs are outside that list — NYSED bars them from diagnosing the condition ABA is provided for and from prescribing or ordering ABA — which is why no New York case should open without a separate diagnosing clinician in the file.[1][18]
No instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses,” plus the “symptom severity level/level of support (if referral is from an ASD-diagnosing provider).” On the ABA side the manual asks only that the treatment plan record the “assessment methodology (e.g., antecedent-behavior-consequence log, behavioral observation/sampling, functional behavior assessment, self-monitoring/self-report, inventory, etc.)” and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results of assessment.” Named-instrument requirements in New York are a managed-care overlay, not a state rule.[1]
Required — and at the fee-for-service layer it is the entire authorization gate, because nothing in the current manual requires prior approval. The referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP or PA; it is “valid for no more than two years”; and it must carry seven elements: age of the patient, the ASD or Rett Syndrome diagnosis, date of initial diagnosis, co-morbid diagnosis if applicable, symptom severity level/level of support, “statement the patient needs ABA services,” and the DSM-5 Diagnostic Checklist. An incomplete referral is the only thing standing between an FFS family and a booked assessment.[1]
Allowed on the same footing as in-person care, with no ABA-specific code list. The NYS Medicaid Telehealth Policy Manual (updated July 2026) adds “Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy” to the telehealth-provider definition under 18 NYCRR Part 538, and states that providers “who are authorized to provide in-person services, are authorized to provide such services via telehealth if such telehealth services are appropriate to meet the needs of the patient and are within the scope of practice of the provider.” The limit is the code itself: “Providers must meet all elements of the procedure code via telehealth.” That includes the assessment codes: the manual’s definition says services provided via telehealth “include assessment, diagnosis, consultation, treatment, education, care management and/or self-management,” and its Section 10 list of service-specific restrictions (in-person-only initial assessments in adult care facilities, adult day health, home health and hospice; OMH, OPWDD, school-based health center and other carve-outs) names no ABA restriction. So 97151 and 97152 (initial or reassessment) may be delivered by audio-video when every element of the code can be met remotely; 97152 is defined as “face-to-face with the patient,” so plan for a technician on site or in-person delivery where that cannot be done by video. Bill with modifier 95 or GT for audio-video and place of service 02, 10 (the member’s home) or 11 — the manual encourages POS 11 where the in-person visit would have been POS 11, because payment parity (Public Health Law § 2999-dd, in effect until April 1, 2028) pays telehealth at the in-person rate. The ABA manual adds the supervision rule: supervision “may be conducted via a synchronous interactive audio and video telecommunication system,” but the two required monthly contacts must be face-to-face and real time and “may not occur telephonically, via email or text messaging.” Managed-care plans publish their own overlays (UHC Community Plan allows 97155, 97156 and 97157 at POS 02 for approved virtual-visits providers).[19][1]
Nothing to decide at the fee-for-service layer: the eMedNY ABA manual requires no prior authorization, so the referral is the whole gate (FFS’s own new PA clocks — standard requests “adjudicated within seven days from the date received, provided all necessary documentation is included,” expedited within 72 hours, effective January 1, 2027 — only bite on services that carry a PA). For the majority of children, who sit in a Medicaid Managed Care plan, the state model contract sets the clock: a prior authorization request is decided “within three (3) business days of receipt of necessary information, but no more than fourteen (14) days after receipt of the Service Authorization request,” expedited requests within 72 hours, and a request for “more of an authorized service than what is currently authorized” (a concurrent review — reauths and unit increases) “within one (1) business day of receipt of necessary information”; either clock may be extended up to 14 days. Federal law caps the outer limit at 7 calendar days for plan rating periods starting on or after January 1, 2026 (42 CFR 438.210(d)). The state sets no reauth submission lead time; plans publish their own.[1][35][24][36]
Medicaid pays last. “The Medicaid Program is designed to provide payment for medical care and services only after all other resources available for payments have been exhausted; Medicaid is the payer of last resort,” and “Providers must bill all applicable insurance sources before submitting claims to Medicaid. Payment from those sources must be received before submitting a Medicaid claim.” So check MEVS for a third-party coverage code at intake, bill the commercial plan first, then bill eMedNY for the balance — a claim pushed past Medicaid’s 90-day filing limit by the other payer’s processing must reach Medicaid within 30 days of that payer’s determination, with the Explanation of Medical Benefits on paper claims. Two practical twists: a child with other insurance may be excluded from managed care (“Enrollees who have other third party insurance so that managed care enrollment is not cost-effective”), which lands them in FFS, where ABA has no PA at all; and if the child is in a plan, the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” A provider may not refuse service because a third party is liable. The manuals state no pay-and-chase exception for ABA.[37][21][24]
Coverage decides whether New York Medicaid (NYS DOH / eMedNY) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Effective October 1, 2025 the supervision rules have hard numbers. “An LBA can supervise no more than six CBAAs/unlicensed individuals at a time”; “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month”; and “supervision must include at least two face-to-face, real-time contacts per month” — explicitly not telephonic, email or text — with the LBA observing the technician delivering services in at least one. One of the two contacts may be a small-group meeting. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs separately require direct supervision, cannot exceed six per LBA, and their supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Because an LBA may not delegate any task inside the ABA scope of practice, supervision capacity is a hard cap on census. The CBAA half of the cap is also statute, for every payer: Education Law § 8802 says “no licensed behavior analyst shall supervise more than six certified behavior analyst assistants”; the statute sets no number for unlicensed technicians, so the combined six-supervisee cap covering unlicensed staff is the Medicaid manual’s rule.[1][4][34]
No ABA-specific ceiling, but the federal Medicaid claim edits apply. The eMedNY ABA manual publishes no per-day unit cap, weekly hour cap or annual maximum; its only quantitative limits are group size (97154 and 97158 “can only be billed for a group treatment session of no more than 8 individuals”) and documenting “total hours of service per week.” The per-day ceiling comes from Medicaid NCCI: CMS requires that “the Medicaid NCCI methodologies must be applied to Medicaid fee-for-service (FFS) claims,” and “States are not permitted to make unilateral decisions on the application of Medicaid NCCI edits.” The public Medicaid practitioner MUE file for dates of service October 1 – December 31, 2026 lists, per code, per provider, per beneficiary, per day: 97151 – 32 units, 97152 – 16, 97153 – 32 (8 hours), 97154 – 18, 97155 – 24, 97156 – 16, 97157 – 16, 97158 – 16 (0362T/0373T, which New York’s ABA fee schedule does not carry, 16 and 32). These are claim (coding) edits, not authorization limits: “MUEs are coding edits, not medical necessity edits,” applied to one claim line at a time, and units over the value on a line are denied. CMS notes its public file “should NOT be used by state Medicaid programs as their edit file” — eMedNY’s production edit table is not published, so treat these as the reference values. For managed care, CMS calls NCCI “desirable but optional”; the plan’s authorized units are the operative ceiling there.[1][25][27][2]
The person who prepared the note signs it, and the supervising LBA countersigns a CBAA’s: the supervisor “should assess each patient’s/client’s progress at least every 6 months or as needed, and review and sign treatment notes and reports prepared by the CBAA supervisee.” Documentation of supervision itself “should be recorded in the patient file of the NYS Medicaid member.” Clinical documentation “should include, but may not be limited to” the treatment plan with assessment and goals, specific goals with associated data, total hours of service per week and who provided them (including caregiver training), and the location(s) of services. Retention: “a minimum of six years and, for minors, until the patient turns 22 years of age.”[1]
“LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings.” Then the line that shapes every New York intake: “Note: NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record “location(s) of services (such as office, residence, community),” so setting is documented, not assumed. Managed-care plans have followed the state here rather than deviating — Fidelis stopped covering school-setting ABA on 9/1/2023 and MVP administratively denies any ABA code billed with POS = School from 7/1/2025.[1]
The LBA is the billing provider, always. “An LBA must be enrolled with the NYS Medicaid FFS program to receive reimbursement for ABA services provided to a NYS Medicaid FFS or MMC member,” and “CBAAs cannot bill the NYS Medicaid program directly” — they enroll as OPRA providers and their work is billed by the supervising LBA. The role mapping is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim.” For non-enrolled unlicensed aides and LBA limited-permit holders, the supervising LBA’s NPI fills Billing, Supervising and Rendering alike. Technicians (RBTs or not) do not enroll with NYS Medicaid at all: the manual defines the technician as an “unlicensed individual” who “is not licensed, certified or registered by the State of New York as an ABA provider” and attaches no RBT or other credential to the role. An Article 28 facility bills instead on the Ordered Ambulatory Fee Schedule, with its LBAs/CBAAs enrolled as OPRA providers and affiliated with the facility.[1]
Not answered for 97153 with 97155. The ABA manual’s only same-session provision runs the other way — it tells you when 97155 may be counted toward the 5% supervision minimum, not whether a technician’s 97153 units may be billed for the same clock time. The manual’s two stated code restrictions are unrelated: “CPT code 97156 & 97157 can only be billed when the service is delivered in concert with care of the patient as part of the child’s treatment plan,” and 97154/97158 “can only be billed for a group treatment session of no more than 8 individuals.” On the federal edit side, the Medicaid NCCI practitioner PTP file for October–December 2026 contains no procedure-to-procedure edit pairing 97153 with 97155 (the only ABA-to-ABA pair it lists is 0362T with 97152), so no national Medicaid edit bundles the two codes; whether eMedNY lets both be billed for the same clock time is still not written down.[1][26]
Blocked on: eMedNY provider services (800) 343-9000 and the Medicaid NCCI edit files applied to the ABA fee schedule; for a managed-care member, the plan’s claim-edit policy.
At the fee-for-service layer, no — the current FFS policy manual contains no PA requirement; the gate is a practitioner referral valid up to 2 years. But most children are in Medicaid Managed Care, and every major MMC plan does require prior authorization under its own process.
Members under 21 with ASD as defined by DSM-5 and/or Rett syndrome, referred by a NYS-licensed, Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP, or PA. Adults 21+ and non-ASD/Rett diagnoses are not covered.
A single statewide FFS rate per code: $19.26 per 15-minute unit for 97151/97152/97155/97156 and $3.31 per member for the group codes. Technician-delivered 97153 pays $9.63, current as of October 1, 2026 (NYS Medicaid Update, August 2026), down from $14.45 through September 30, 2026. MMC plans negotiate their own rates.
Yes, a cut, now in effect. The August 2026 NYS Medicaid Update (Vol 42 No 9) says that, as authorized by the FY 2026-27 enacted budget, “effective October 1, 2026, the reimbursement for CPT code 97153 will be reduced to $9.63/per unit” for fee-for-service. It is the third 97153 step: $19.26 before 10/1/2025, $16.85 from 10/1/2025, $14.45 from 4/1/2026, $9.63 from 10/1/2026. No other ABA code changed, and no later change had been announced when we re-checked on October 18, 2026 (the only later issue, the September 2026 Special Edition, Vol 42 No 10, concerns practitioner-administered drugs and says nothing about ABA). MMC plans pay by contract; ask each plan whether it follows the FFS cut.
Two rules. Licensure: Education Law § 8802 says “no licensed behavior analyst shall supervise more than six certified behavior analyst assistants”; Article 167 sets no number for unlicensed staff. Medicaid (FFS and MMC, since October 1, 2025): the eMedNY ABA manual says “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time (e.g., one CBAA and five unlicensed individuals or two CBAAs and four unlicensed individuals, etc.)”, with supervision of at least 5% of each technician’s monthly service hours and two face-to-face real-time contacts a month. In New York a BCBA must also hold the NYSED LBA license to supervise.
Not on the BCBA credential alone — New York requires NYSED licensure as a Licensed Behavior Analyst (LBA) to enroll and bill. CBAAs enroll as non-billing providers under a supervising LBA.
No to both. The eMedNY ABA manual defines the technician as an “unlicensed individual” not licensed, certified or registered by the state as an ABA provider, with no RBT requirement. Technicians do not enroll; the supervising LBA bills their work with the LBA’s NPI as Billing, Supervising and Rendering provider. Plans may add their own staffing rules.
Yes, when every element of the code can be met remotely. The NYS Medicaid Telehealth Policy Manual (July 2026) includes NYSED-licensed ABA providers, says covered telehealth services include assessment, and lists no ABA restriction. Bill with modifier 95 or GT and POS 02, 10 or 11. Managed-care plans can be stricter, so check the plan.
For fee-for-service, an NYSED-licensed LBA can enroll through eMedNY; the ABA manual states no cap or moratorium. For managed care, each plan decides whether to contract, and eMedNY enrollment is required first.
On fee-for-service there is no authorization; the referral (valid up to 2 years) is for ABA services, not a named provider, and the treatment plan must carry transition and coordination plans. For a managed-care member, ask the plan whether its authorization can move or a new request is needed.
Six at a time. Since October 1, 2025 the eMedNY ABA manual says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each unlicensed technician for at least 5% of their monthly service hours, and must hold at least two face-to-face, real-time contacts a month, observing service delivery in at least one. The supervisor must be a NYSED-licensed behavior analyst — BCBA certification alone is not a New York license — and Education Law § 8802 separately caps an LBA at six CBAAs for every payer.
90 days from the date of service for fee-for-service claims, unless delayed by circumstances outside the provider’s control (then within 30 days of the delay ending, with a delay reason code); all claims must be finally payable within two years. Does EVV apply to ABA in New York? No — ABA codes are not on the state’s EVV code list.
eMedNY runs weekly cycles from Thursday to Wednesday. Send electronic claims before 6:00 PM on Monday for the best chance of the current cycle; the check date is the following Monday and EFT goes out on the check release date, the Wednesday two weeks and two days after the check date. Rejected claims must be corrected within 60 days of notification. Managed-care members are paid by their plan under Insurance Law § 3224-a (30 days electronic, 45 days paper).
Fee-for-service has no reauthorization, but the treatment plan must be updated at least every 6 months with updated goals and data: baseline data in objective terms and current data collected the same way so progress can be measured. Graphs are not required by the state manual; managed-care plans can require them.
The state ABA manual sets no daily cap. The federal Medicaid NCCI medically unlikely edit for October–December 2026 is 32 units (8 hours) of 97153 per provider, per child, per day; 97155 is 24 units and 97151 is 32. These are claim edits, not authorization limits. Managed-care plans cap units through the authorization.
No. New York Medicaid bills ABA only on CPT 97151–97158; the ABA fee schedule (effective October 1, 2026) lists no HCPCS H-codes and no 0362T or 0373T.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo